Summary of the impact

Alternatives to acute admission in mental health are crucial, not least because of the high cost of inpatient care. We have carried out a major research programme that includes the only randomised controlled evaluation of crisis resolution teams and the only major UK study of crisis houses, which are community-based, residential alternatives to hospital admission. This programme demonstrated the efficacy of community treatment and has significantly influenced decision making at a local and national policy level, including commissioning guidance and three sets of NICE guidelines. This has contributed to changes in the way acute services for severely mentally ill adults are configured in the NHS, and internationally.

Underpinning research

Psychiatric hospitals are still a prominent component of UK mental health systems despite the closure of large asylums: the Information Centre for Health and Social Care estimates that 550,000 of England's 1.6 million users of specialist services for people with severe mental health problems (such as schizophrenia or bipolar disorder) were admitted to hospital during the year from April 2012. The high associated costs (£655 million for acute psychiatric wards for adults of working age in 2012/13), service users' reluctance to be admitted and reports of negative experiences in hospital, and doubts about the therapeutic quality of wards drive the quest for effective alternatives to admission. UCL has led nationally and internationally over the past decade on research on these. Led by Professor Sonia Johnson, we have researched both major current types of alternative: crisis resolution teams, which provide crisis assessment and intensive home treatment, and crisis houses, which provide a community residential alternative to admission.

A national policy in the UK mandated the introduction of crisis teams in 2001. This was widely criticised for lack of evidence, as studies cited to support it were at least two decades old and conducted in a very different service context from the current NHS. Our research has provided the necessary underpinning for their continuing implementation and development in the NHS. Our initial study on crisis teams was a naturalistic investigation of the impact of their introduction [1]. This was followed by a widely cited study that remains internationally the only randomised controlled trial of the crisis resolution team model in a deinstitutionalised service system [2] accompanied by a health economic study demonstrating cost-effectiveness [3].

Subsequently Johnson has led a nationwide investigation of the impact on the workforce of working on acute wards and in crisis teams [4]. Norway has now followed England in adopting crisis teams as a national model, and Johnson has participated in a multicentre study assessing the Norwegian implementation. Our programme of research on crisis teams continues through the CORE study (2011-16), funded by the National Institute for Health Research Programme Grants for Applied Research. The initial stage of this has involved a nationwide investigation of experiences of implementing the crisis team model and of how best practice may be achieved in these teams: we are now conducting a national pilot of a fidelity scale based on the resulting model of good practice.

The second form of admission diversion we have investigated is the crisis house, which provides 24-hour support and treatment in a domestic, community-based setting. Despite a 50-year history and strong support from service users, evidence for effectiveness and potential role in the mental health care system was limited prior to the studies of the past 10 years in which UCL has participated, so that they featured little in mental health policy and guidance on service planning. Following an initial study of service user characteristics and experiences in a women's crisis house in North London, we have, in collaboration with colleagues at Kings College London, conducted the study that is now the main UK evidence source on residential alternatives to acute admission, the Alternatives Study [5, 6]. This demonstrated that crisis houses manage in the community a group that overlaps substantially with acute hospital ward populations, though with less risk to others in acute wards. We have also found that service users prefer crisis house care to inpatient admissions, and that it is associated with lower mean costs and similar subsequent readmission rates.

References to the research

Peer reviewed funding

• Evaluation of a Women's Crisis House (1999-2002): S. Johnson (CI), S. Pilling, P. Bebbington, J. Dalton, S. McNicholas. London Region Research and Development Responsive Funding Committee. £68,000

• The Alternatives Study (2005-2009): S. Johnson and M. Slade (Joint CIs), G. Thornicroft, J. Boardman, D. Osborn, N. Morant, G. Shepherd, V. Pinfold, S. Byford, M. Leese. NHS Service Delivery and Organisation Programme. £455,000

• National Acute Care Research Group (2006-) Convened by S. Johnson. Mental Health Research Network Group, awarded by national competition. £5,000

• Pilot patient preference trial of women's crisis houses (2006-2009): L. Howard (IOP - CI), S. Johnson, A. Boocock, M. Leese, G. Thornicroft, P. Cutting, S. Byford. Medical Research Council. £260,000

• A national investigation of in-patient staff morale (2006-2010) S. Johnson (CI), D.Osborn, F.Nolan, S.Wood, M.Paul, R.Araya, H.Killaspy, S.Pilling) NIHR Service Delivery and Organisation Programme. £300,000.

• An investigation of therapeutic alliance and its relationship to service user satisfaction in acute psychiatric wards and crisis residential alternatives (2011-2013) S. Johnson (CI), B. Lloyd-Evans, R. McCabe, M. Slade, H. Gilburt, F. Nolan, N. Morant). NIHR Service Delivery and Organisation Programme. £135,000

• Optimising team functioning, preventing relapse and enhancing recovery in crisis resolution teams: the CORE programme (CRT Optimisation and RElapse prevention (2011-2016). S. Johnson (CI), T. Weaver, R. Gray, C. Henderson, O. Mason, B. Lloyd-Evans, D. Osborn, F. Nolan, A. Faulkner, N. Morant, L. Addison, S. Morris, S. Onyett. National Institute of Health Research Programme Grant. £2,005,000

Details of the impact

The principal contribution of this programme of work has been to provide an evidence base for informed decision making at local and national policy levels regarding the configuration of acute services for severely mentally ill adults. Our work has been widely cited, and has contributed towards sustaining the crisis resolution/home treatment model beyond the initial period when it was mandatory national policy, and towards supporting the introduction of new residential crisis houses in the community. The benefits of a policy on acute mental health care that is well founded in evidence are considerable: the Information Centre for Health and Social Care estimates that acute inpatient wards cost £655 million per year and crisis resolution teams £256 million in England. Effective alternatives to acute admission represent significant cost savings to the NHS and furthermore improve an aspect of service provision that users frequently cite as one of the most important issues for them, and the one with which they are least satisfied.

Guidance for Commissioners: The Joint Commissioning Panel for Mental Health, co-chaired by the Royal College of Psychiatrists and the Royal College of General Practitioners in collaboration with a range of national voluntary and statutory bodies, has produced recommendations on adult mental health services which are intended for use by Clinical Commissioning Groups to inform local commissioning priorities, strategies and service redesign; and for Health and Wellbeing Partnerships to inform Health and Wellbeing Strategies. Their guidance on services for severe problems in crisis cites our work in its recommendations that: crisis teams are an efficient way of managing mental health crises; that they can also be used in early psychosis; and that crisis houses are beneficial for a sub-group in crisis. Johnson was part of the expert group making these recommendations [a]. The NHS London commissioning programme also produces guidance on acute care models and cites our work in support of recommendations on crisis teams and crisis houses [b].

NICE Guidelines: Our work is cited in guidelines on bipolar disorder, schizophrenia and service user experience. Bipolar disorder: our study is cited as the main evidence to support a recommendation that crisis teams be made available for people with bipolar disorder [c]. Schizophrenia: the current (2009) guideline on schizophrenia cites our trial (paper 1) as evidence that crisis teams may reduce hospitalisation for people from Black and Minority Ethnic backgrounds as well as for White service users [d]. In the 2013 revision of the NICE guidelines, for which Johnson is on the Guideline Development Group, evidence on mental health teams has been reviewed in more detail, and our trial (paper 1) will be cited as the only recent evidence supporting the recommendation that crisis resolution teams be available for people with schizophrenia/psychosis. Our work on crisis houses (papers 4 and 5) is also discussed. This guideline is now at a late stage of drafting, for release in late 2013. Service user experience in adult mental health: cites our work on crisis houses to support a recommendation that these should be available as they are greatly preferred by service users [e].

Reports by national voluntary sector bodies: Several recent reports by influential national bodies cite our work in support of their recommendations. The national mental health charity MIND has conducted a national enquiry into acute care and is conducting a subsequent report on acute care. The enquiry report cites our studies in support of its strong advocacy of the crisis house model. Subsequently Johnson and colleagues have collaborated with MIND on their acute care report: Johnson has appeared with MIND representatives to give evidence on acute care to the All Party Parliamentary Group on Mental Health. We have released to them early findings from our national survey on crisis teams in the CORE study and these have formed the basis of recent press releases and media coverage on acute care [f]. The Kings Fund has recently reported on ways of enhancing the productivity of mental health services. This major report cites four of our papers on crisis teams and crisis houses in support of recommendations that alternatives to admission need to be further developed in order to increase the efficiency and acceptability of mental health services [g]. The think tank Centre for Social Justice has also reported on mental health services nationally. It advocates reform of mental health service delivery, citing our work to support the recommendation for further development and implementation of the crisis team and crisis houses [h].

International impact: A report by the World Psychiatric Association making recommendations for the development of community mental health services makes recommendations in support of crisis teams and crisis houses in countries with well-developed mental health systems [i]. Our work is also cited in support of new national policies in documents from Norway and Flanders (Belgium), and in documents supporting local plans and policies within mental health Trusts. In Norway, for example, our work influenced recommendations for crisis resolution teams in Norway, developed by the Acute Network for the Norwegian Directorate of Health [j]. Johnson has been asked to speak on crisis teams in relation to the introduction of new policies in Norway, Flanders, Scotland and Wales and is regularly contacted by service planners and clinicians from a variety of countries where this model has attracted interest.

Sources to corroborate the impact

[a] Joint Commissioning Panel for Mental Health `Mental health and wellbeing commissioning pack', Commissioning Framework, Volume 3. Six papers from our group are cited in the recommendations for severe problems in crisis http://www.nice.org.uk/guidance/index.jsp?action=download&o=64924
http://www.jcpmh.info/commissioning-tools/cases-for-change/crisis/what-works/.

[b] Models of mental health care for London, 2011. Cites four papers from our group — see pages 19 and 54 http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/2.-Models-of-care-low-res.pdf

[c] NICE guidelines on Bipolar affective disorder guideline (CG28). References to our work on p. 468-9 of full guideline: http://www.nice.org.uk/nicemedia/live/10990/30194/30194.pdf

[d] NICE guidelines on Schizophrenia (2009). Cites our trial on p. 464. http://www.nice.org.uk/nicemedia/live/11786/43607/43607.pdf. Revised guideline is also out for consultation: http://www.nice.org.uk/guidance/index.jsp?action=download&o=64924. This cites 11 papers from our group.

[e] NICE guidelines CG 136 on Service user experience in adult mental health (2012). Reference to our work on p. 225. http://guidance.nice.org.uk/CG136/Guidance/pdf/English

[f] Mental health crisis care: commissioning excellence. A briefing for Clinical Commissioning Groups. Mind. November 2012. See p. 11 for references to our work: ref. 12 our work on crisis houses; ref. 7 to early findings released to them from the CORE programme grant.
http://www.mind.org.uk/assets/0002/3540/CCG_crisis_care_briefing_November_2012.pdf. (Copy available on request).
Minutes of the parliamentary group are available here (and copy available on request):
http://www.mind.org.uk/assets/0002/2568/APPGMH_Crisis_Care_meeting_notes_23.10.2012.pdf. Mind's crisis care report was also covered in the media: http://www.mirror.co.uk/news/uk- news/two-in-five-nhs-mental-health-1461694

[g] Mental health and the productivity challenge: improving quality and value for money, 2010. http://www.kingsfund.org.uk/publications/mental_health_and.html

[h] Completing the Revolution: transforming mental health and tackling poverty, 2011. Cites our work on crisis teams (Johnson et al., p. 236) and crisis houses (Howard et al. 246) http://www.centreforsocialjustice.org.uk/UserStorage/pdf/Pdf%20reports/CompletingtheRevoluti on.pdf

[i] World Psychiatric Association citing our work in review of key European evidence on community mental health care implementation: http://onlinelibrary.wiley.com/doi/10.1002/j.2051-5545.2011.tb00060.x/full

[j] Letter to corroborate this impact from Chair, the Acute Network, Norway. Copy available on request.